Healthcare Provider Details

I. General information

NPI: 1053099754
Provider Name (Legal Business Name): KODEE WALLS PHD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/11/2023
Last Update Date: 07/11/2023
Certification Date: 07/11/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

600 N EAGLESON AVE
BLOOMINGTON IN
47405-3190
US

IV. Provider business mailing address

1209 E CHESTNUT CT
BLOOMINGTON IN
47401-6650
US

V. Phone/Fax

Practice location:
  • Phone: 812-855-5711
  • Fax:
Mailing address:
  • Phone: 785-209-2914
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103TC1900X
TaxonomyCounseling Psychologist
License Number2547
License Number StateKS

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: